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Departmental case notes audit: A quality assurance measure in a changing organizational climate.

Byline: Mansoor Dilnawaz and Nadia Iftikhar

Abstract

Background

A clinical audit measures practice against standards. It aims to deliver safe and quality care through a systematic approach. The research focuses on the question, "what is the right thing to do?" whereas the audit aims to see if we are doing the right thing in the right way.1-4

Aims and Objectives

To highlight the importance of meticulous record keeping in clinical case notes.

Methods

20 case notes were examined from the dermatology ward. The method of data collection was retrospective. The basis of proposal was local guidelines. The audit type was Process. The standard set was "100%.

Results

The result showed 75% compliance with our local guidelines in the analyzed case sets.

Key words

Clinical audit, quality, safety.

Introduction

Clinical audit falls under the domain of clinical governance. It is a key component, which aims to provide safe and quality clinical care.2 It is important to incorporate it at all levels of service delivery. The staff should be provided with training and protected time to undertake it on a regular basis.1-4 Audit runs in the form of a spiral and aims to bring about incremental improvement in a healthcare system. Standards form the basis of audit and they are set on achievable goals and perceived importance in a given setting and health care system.5-10

Patients and Methods

20 case notes were analyzed from the dermatology ward. The method of data collection was retrospective. The basis of proposal was local guidelines. The audit type was Process. The sample source was case-notes from the dermatology ward. The sample size was 20. A data collection proforma was used. The collected data was analyzed according to the pre-set criteria and standards. The criterion was "there should be meticulous record keeping for all patients". The standards were set at 100% within the domains that there should be:

1a. A hand written record?

1b. Is the clinician identified?

1c. Is it legible?

2. The patient should be identified on each page (name, personal number, age, disease)?

3. There should be a clear diagnosis or clinical problem?

4. There should be a clear management plan?

The inclusion criteria included random analysis of case notes from in-patients. The exclusion criteria included outpatients notes.

Results

(Table 1 and Table 2) The above standards were met in most of the examined case notes. However in 25% of the notes, the patients were not categorically identified with their demographic details on each of the continuation sheets as per our local guidelines.

Discussion

Clinical audit in its true essence means are we practicing evidence-based medicine according to the set standards? It is an integral part of clinical governance. The aim is to provide safe and high quality care to the patients. It is a quality assurance measure and improves clinical care and service delivery. Audit identifies areas for improvement, education and training.4-6 An audit can relate to structure which includes staffing and facilities, process like are checklists, protocols, guidelines, record keeping, waiting times, trainee's attendance, treatment and outcome for example satisfaction surveys.4-10

Clinical audit cycle identifies every step, responsibilities and purpose from the outset (Figure 1).

Medical record keeping lies at the heart of clinical care. It is vital to have an explicit, meticulous, legible and thorough care pathway and care plan for enhanced clinical care. This helps in avoiding adverse and untoward incidents in any healthcare organization. It is an integral part of day-to-day practice and relates to health care professionals at all levels.3-10

Summary

A summary of the audit is presented in (Table 3).

Table 1

###1###2###3###4###5###6###7###8###9###10

1a

1b###a###a###a###a###a###a###a###a###a###a

1c

2###a###a###X###X###X###a###a###a###a

3

4

Table 2

###11###12###13###14###15###16###17###18###19###20

1a

1b###a###a###a###a###a###a###a###a###a###a

1c

2###a###a###a###a###a###X###a###a###X###a

3

4

Table 3

Rationale###Meticulous record keeping

Objective(s)###To examine the standard and quality of in-patients notes

Project type###Process

Basis of proposal###Local guidelines

Criteria###There should be meticulous record keeping for all patients

Standard(s)###100% case-notes should have an explicit and legible management plan and

###demographic details

Sample source###Case-records of in-patients

Sample size###20 case-notes

Data collection/ analysis###Retrospective

Results###The result showed 75% compliance with our local guidelines

Recommendations###To rectify the areas for improvement

RE-AUDIT###6-months

References

1. Smith R. Audit and research. BMJ. 1992;305:905-6.

2. Scally G, Donaldson LJ. Clinical governance and the drive for quality improvement in the new NHS in England. BMJ. 1998;317:61-5.

3. Grimshaw JM, Shirran L, Thomas R, Mowatt G, Fraser C, Bero L. Changing provider behavior: an overview of systematic reviews of interventions. Med Care. 2001;39(suppl 2):112-45.

4. National Institute for Health and Clinical Excellence. Principles of best practice in clinical audit. London: NICE, 2002.

5. Jamtvedt G, Young JM, Kristoffersen DT, O' Brian MA, Oxman AD. Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2006;(2):CD000259.

6. Fraser R, Baker R. The clinical audit programme in England: achievements and challenges. Audit Trends. 1997;5:131-6.

7. Irvine D, Irvine S. Making sense of audit. Oxford: Radcliffe Medical Press; 1991.

8. Jones T., Cawthorn S.; What is Clinical Audit?. Evidence Based Medicine, Hayward Medical Communications, 2002

9. Starey N. 'What is clinical governance?', Evidence-based medicine, Hayward Medical Communications, What is clinical governance?***

10. Jamtvedt G, Young JM, Kristoffersen DT, O'Brien MA, Oxman AD. Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2006;(2):CD000259.
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Publication:Journal of Pakistan Association of Dermatologists
Geographic Code:9PAKI
Date:Sep 30, 2017
Words:1143
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